SELF-CARE ASSESSMENT WORKSHEET

This assessment tool provides an overview of effective strategies to maintain self-care. After
completing the assessment, you can move on to developing a full self-care plan.
 
Using the scale below, rate the following areas in terms of frequency:
5 = Frequently 4 = Occasionally 3 = Rarely 2 = Never 1 = It never occurred to me
Physical Self-Care Emotional Self-Care
___ Eat regularly (e.g. breakfast, lunch and ___ Spend time with others whose company you
dinner) enjoy
___ Eat healthy ___ Stay in contact with important people in your
___ Exercise life
___ Get regular medical care for prevention ___ Give yourself affirmations, praise yourself
___ Get medical care when needed ___ Love yourself
___ Take time off when needed ___ Re-read favorite books, re-view favorite
___ Get massages movies
___ Dance, swim, walk, run, play sports, or do ___ Identify comforting activities, objects, people,
some other physical activity that is fun relationships, places and seek them out
___ Take time to be sexual—with yourself, with a ___ Allow yourself to cry
partner ___ Find things that make you laugh
___ Get enough sleep ___ Express your outrage in social action, letters
___ Wear clothes you like and donations, marches, protests
___ Take day trips or mini-vacations ___ Play with children
___ Other: ___ Other:

Psychological Self-Care Spiritual Self-Care

___ Make time for self-reflection ___ Make time for reflection
___ Have your own personal psychotherapy ___ Spend time with nature
___ Write in a journal ___ Find a spiritual connection or community
___ Read literature that is unrelated to school ___ Be open to inspiration
___ Let others know different aspects of you ___ Cherish your optimism and hope
___ Notice your inner experience—listen to your ___ Be aware of nonmaterial aspects of life
thoughts, judgments, beliefs, attitudes, and ___ Try at times not to be in charge or the expert
feelings ___ Be open to not knowing
___ Engage your intelligence in a new area, e.g. ___ Identify what is meaningful to you and
go to an art museum, history exhibit, sports notice its place in your life
event, theater performance ___ Have experiences of awe
___ Practice receiving from others ___ Read inspirational literature (talks, music,
___ Be curious etc.)
___ Say “no” to extra responsibilities sometimes ___ Other:
___ Other:

Adapted by BWell Health Promotion from: Transforming the Pain: A Workbook on Vicarious

Traumatization. Saakvitne, Pearlman & Staff of TSI/CAAP (Norton, 1996)

 DEVELOP A SELF-CARE PLAN
1. List the self-care habits you are using now to manage stress and stay healthy:
(I get at least 8 hours of sleep at night)

2. List the self-care habits you would like to use but are not currently practicing:
(Practicing yoga regularly)

3. Identify the obstacles keeping you from practicing these habits:

(I don’t practice yoga regularly because I don’t have the time to)

4.What solutions can you come up with to address the obstacles you listed:
(I could free up time for myself by watching less TV or waking up earlier)

5. Reread the self-care habits you wrote down for item 2.  Select one of the habits
you would like to begin practicing and complete the sentences below.
Today, I commit to…
 
 

I want to do this because…

 
 

I will accomplish this by...